Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator

Published:September 25, 2020DOI:

      Background and Aims

      EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance.


      This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE.


      Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis.


      We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.


      AE (adverse event), CUSUM (cumulative sum), EUS-GE (EUS-guided gastroenterostomy), GOO (gastric outlet obstruction), LAMS (lumen-apposing metal stent), LC (learning curve)
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      Linked Article

      • Learning curves for EUS: single operators, endoscopy teams, and institutions
        Gastrointestinal EndoscopyVol. 93Issue 4
        • Preview
          We read with interest the article by Jovani et al.1 The authors concluded that based on the performance of a single operator, proficiency and mastery for EUS-guided gastroenterostomy (EUS-GE) are achieved after 25 and 40 procedures, respectively. Another recently published single-operator study from a different institution reported that 7 EUS-GE cases were adequate to achieve efficiency.2 The adverse events from these 2 endoscopists showed discrepancy: 5.6% (4 of 73 cases) in Jovani et al1 versus 26% (6 of 23 cases) in Tyberg et al.
        • Full-Text
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      • EUS-guided gastroenterostomy: closing knowledge gaps by evaluating learning curves
        Gastrointestinal EndoscopyVol. 93Issue 5
        • Preview
          Lumen-apposing metal stents (LAMSs) have greatly facilitated EUS-guided drainage in established and emerging indications. Off-label use of LAMSs to create various GI anastomoses has continued to evolve in parallel. This is in stark contrast with previous endoscopic techniques for the creation of GI anastomoses, which never gained clinical acceptance.1 EUS-guided GI anastomosis (EUS-GIA) by transmural placement of LAMSs was proved feasible in preclinical studies nearly a decade ago.1,2 After these seminal experiments, EUS-GIA was first used clinically to allow through-the-stent transluminal ERCP in Roux-en-Y hepaticojejunostomy3 and gastric bypass4 patients.
        • Full-Text
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